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Senior Focus Hawaii

A. Medicare is a federal health insurance program for people age 65 or older and certain disabled persons. It is run by the Centers for Medicare and Medicaid Services (CMM) of the U.S. Department of Health and Human Services. There are two parts, Part (A) and Part (B).

1. Medicare Part A. Medicare Part (A) pays for inpatient hospital care, limited care in a skilled nursing facility, home health care and hospice care. If you are receiving social security benefits you are automatically enrolled on the first day of the month you turn age 65. Eligibility does not depend upon income or resources.

2. Medicare Part B. Medicare Part (B) covers only skilled, not custodial, nursing home care (42 U.S.C. 1395f(a)(2)(B). Skilled nursing home care is care which is:

1. Ordered by a physician;

2. Required on a daily basis;

3. Performed under the direct supervision of a licensed nurse;

4. Reasonable and necessary to the treatment of an illness or injury.

Medicare Part (B) pays for medically necessary doctor services, out-patient hospital services, home health care and a number of other services and supplies that are not covered by Part (A). It is voluntary and requires a monthly premium if you elect to enroll. After a deductible, Part (B) pays for eighty percent (80%) of the reasonable charges of coveraged services.

B. Medicare covers only one hundred (100) days per "benefit." The patient must be admitted to the nursing home within thirty (30) days after having been hospitalized and the patient must have been hospitalized for at least three (3) consecutive days.

C. The patient must make co-insurance payments for days 21-100.

D. Medicare does not pay for long term custodial care. Custodial care is care that is primarily for the purpose of meeting a persons non-medical needs for mobility and activities of daily living (ADLs). These would include walking, getting in and out of bed, bathing, dressing, eating and taking medicine.

E. Medicare Supplemental Insurance (Medigap). Medigap insurance is a health insurance policy designed to supplement medicare. These are available through private insurance companies and are designed to supplement Part (A) and Part (B) of medicare. They generally do not supplement medical expenses not covered by Parts (A) or (B). These policies are regulated by federal and state law. There are ten different levels available ("A" to "J") from very basic to very comprehensive. These policies together with medicare coverage only pay for the physicians "medically necessary" or "customary and reasonable" charges. Any excess over this amount that medicare determines to be an "allowed" charge must be paid by the patient.

F. Medicare + Choice. In addition to medicare, you have a choice of certain medicare managed care plans (HMO's). There are also several private fee for service plans. Under the medicare HMO's, you are provided coverage for Parts (A) and Parts (B) and do not have to pay medicare deductibles or medicare co-payments. As with any HMO, your choice of doctors and coverage outside of the HMO service area may be limited. A private fee-for-service plan allows you to go to any doctor or hospital of your choice but to be covered by the contractual limits of the plan, you may need to go to a doctor or hospital that accepts the terms of the plans payment.

G. Resources. A good source of information and assistance is a volunteer service sponsored by the executive office on aging called "SAGE Plus." The telephone number on Oahu is 586-7299. You can also obtain help with medicare questions on a 24 hour hotline (1-800-Medicare). You may also get information on the net at www.medicare.gov

An excellent resource for information on medicare can be obtained at www.medicare.gov

A good overview of Medicare coverage can be obtained from the city and county of Honolulu Elderly Affairs Division book entitled Deciding "What if?" Go to  www.elderlyaffairs.com and click on the book Deciding "What if?" and scroll to page 39.

The center for Medicare and Medicaid services provides a twenty-four hour a day, seven days a week telephone line to answer your questions about Medicare. Call 1-800-633-4227. The CMS also publishes a very useful handbook entitled Medicare and You. You can obtain this handbook on audio tape, in brail and in large print by calling the same telephone number. The publication number for this book is CMS-10050.

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